[Degenerative joint and spine diseases]

Degenerative joint and spine diseases account for more than 70% of all complaints and functional impairment in the human locomotor system. An expert assessor has to answer questions referring to loss of capability of earning a living and to the extent of an invalidity. He will often be confronted with questions whether or not the body damage is related to an accident. He therefore has to be familiar with accident mechanisms and typical injury patterns. Particular details of examination and imaging important for fulfilling the assessor's task are given. Special hints will be given referring to evaluation of rotator cuff lesions and spine syndromes.

[Disk-related diseases of the lumbar spine as an example for the critical interaction between clinical diagnosis and occupational disease]

First an overview of the significance of musculoskeletal diseases in terms of national economy and social politics is given, and then the historical development of the occupational disease "disk-related spinal disorders" is outlined. The most important court decisions and the actual state of jurisprudence on this matter are summarized, emphasizing the questions which still have to be answered in the course of medical evaluation of a spinal occupational disease. Based on a joint research project on the spinal effects of whole-body vibrations, an analysis of lumbar X-rays is presented which aimed at detecting specific patterns of response corresponding to the respective extent of strain. In spite of a statistically significant relationship between the clinical diagnosis of a lumbar syndrome and the severity of the degenerative radiological changes on the one hand and vibration exposure on the other hand, the evaluation of the lumbar X-rays did not show any clear radiological pattern related to the exposure. Furthermore, starting points for prevention are discussed. With regard to whole-body vibration, the technical possibilities of reducing the amount of vibration load are still not completely exhausted. However, during preventive measures of occupational health usually carried out as medical screening examinations, the occupational health physician again will face some of the same problems which have already been met with respect to the medical evaluation. Thus, a suggestion is made to modify the traditional concepts of the Professional Industrial Associations on occupational diseases in order to take into account the peculiarities of disk-related spinal disorders.

[Is lumbar disk disease an occupational disease? Scientific background, radiological findings, and medical legal interpretations]

AIM

It should be cleared whether or not the interpretation of lumbar disk disease as an occupational disease is justifiable. Which disc changes follow whole-body vibration and can they be distinguished from those which occur constitutionally while aging?

METHOD

Orthopedic meta-analysis of epidemiological and occupational studies concerning the influence of whole- body vibration.

RESULTS

Reliable studies are rare. Severe methodological problems limit the interpretation of difficult relationships. The role of age when working influences begin as well as the stress and behaviour of exposed persons away from the work-place before and while working with whole-body vibration is not known. There is no study which could be called exact according orthopedic criteria. It is therefore not evident that whole-body vibration causes lumbar disc disease.

CONCLUSIONS

After whole-body vibration similar to long term heavy lifting an earlier beginning of disk degeneration in X-ray-studies can be observed. This leads to prevalence differences, which diminish with increasing age. Deviation to the left of the prevalence curve lasts for five to ten years. Whole-body vibration leads to a topographic modification of disk degeneration of the lumbar spine. After long duration exposition an increased amount of spondylotic changes at the thoracolumbar junction and the middle half of lumbar spine can be observed (up to the upper plate of the fourth vertebral body). This can be explained by biomechanic means: whole-body vibration caused by tractor driving and similar long-term exposures leads to traction of the disks of the lower thoracic spine and the upper and middle parts of lumbar spine.

Evaluation of axial and flexural stresses in the vertebral body cortex and trabecular bone in lordosis and two sagittal cervical translation configurations with an elliptical shell model

BACKGROUND

Osteoarthritis and spinal degeneration are factors in neck and back pain. Calculations of stress in clinically occurring configurations of the sagittal cervical spine are rare.

OBJECTIVE

To calculate and compare combined axial and flexural stresses in lordosis versus cervical configurations in anterior and vertical sagittal head translated positions.

DESIGN

Digitized measurements from lateral cervical radiographs of 3 different shapes were used to calculate axial loads and bending moments on the vertebral bodies of C2-C7.

METHODS

An elliptical shell model was used to model horizontal cross-sections of the vertebral bodies of C2 through T1. Axial and flexural stresses were calculated with short compression block equations. Elliptical shell modeling permitted separation of stresses into cortical and inner medullary regions. Digitized radiographic points were used to create polynomials representing the shape of the sagittal cervical curvatures from C1 to T1. To calculate bending moments at each vertebral segment, moment arms from a vertical line through C1 were determined from digitizing.

RESULTS

Compared with the normal lordosis, stresses on the anterior vertebral body cortical margins of C5-T1 in the sagittal translated postures are compression rather than tension. At the posterior vertebral bodies in the anteriorly translated position and vertically translated postures, the stresses change from compression to tension at C5 through T1. In absolute value (ABS) compared with values at the same segments in a normal lordosis, the magnitude of the combined anterior stresses in the sagittal postures are higher at C5-C7 (eg, ABS[sigma(straight)/sigma(normal)] approximately 1.25 to 4.25).

CONCLUSIONS

Vertebral body stresses are reversed in direction at C5-T1 in sagittal translated postures compared to a normal lordosis. Stress analysis, with implications for bone remodeling, indicates that both sagittal head translation postures, anterior head carriage, and vertical head translation, are undesirable configurations in the cervical spine.

Effect of axial load on the cervical spine: a study of Congolese woodbearers

We studied the cervical spine radiographically of 72 women between 24 and 78 years of age who had carried wood on their head for a mean of 12 (5-41) years and compared the findings with those of 44 women between 21 and 80 years of age who served as controls. The height of the intervertebral discs and the vertebral bodies was statistically lower among woodbearers. Osteophytes were seen infrequently in pre-menopausal women in the study group, and their presence related to age ( P<0.01), short stature ( P<0.01), and the number of years working as a woodbearer ( P<0.05). The medullary canal was narrow in almost half of the post-menopausal woodbearers and narrower in those with degenerative changes ( P<0.01). Listhesis also was more frequent among woodbearers.

[Cervical spondylosis revealed after general anesthesia]

We present a case of complicated postoperative nerve injury. A 70-year-old man complained of partial paralysis and numbness of the left forearm 1.5 hour after operation for femoral artery bypass graft. Postoperative cervical spine MRI revealed cervical spondylotic radiculopathy. The MRI findings could account for his symptom. Not only peripheral nerve injury but the cervical radiculopathy may play an important role in perioperative neuropathy.

[Syringomyelobulbia associated with cervical spondylosis. Pathophysiology and therapeutic implications]

Spinal spondylosis is rarely implicated in syringomyelia. We report the case of a 70-year-old patient with a 10-year history of gait disturbance; constrictive pain of lower limbs and urinary incontinance. Physical examination disclosed spastic tetraparesis. In the upper limbs, deep tendon reflexes were abolished, with hyposthesia and hands amyotrophy. Brain and cervical MRI showed syringomyelobulbia with cervical spondylotic myelopathy. Extensive cervical laminectomy induced a mild clinical improvement. A second MRI performed 6 months after surgery depicted a complete disappearance of the bulbo-medullar cavitation with secondary atrophy. Extradural spondylotic compression of the spinal cord should be firmly considered as an etiology of syringomyelia. A purely extradural decompression could be sufficient to induce regression of the medullary cavitation.

Cervical spinal stenosis: outcome after anterior corpectomy, allograft reconstruction, and instrumentation

OBJECT

The authors undertook a retrospective single-institution review of 261 patients who underwent anterior cervical corpectomy, reconstruction with allograft fibula, and placement of an anterior plating system for the treatment of cervical spinal stenosis to assess fusion rates and procedure-related complications.

METHODS

Between October 1989 and June 1995, 261 patients with cervical stenosis underwent cervical corpectomy, allograft fibular bone fusion, and placement of instrumentation for spondylosis (197 patients), postlaminectomy kyphosis (27 patients), acute fracture (25 patients), or ossification of the posterior longitudinal ligament (12 patients). All patients suffered neck pain and cervical myelopathy or radiculopathy refractory to medical management. Of the procedures, 133 involved a single vertebral level (two disc levels and one vertebral body), 96 involved two levels, 31 involved three levels, and a single patient underwent a four-level procedure. Clinical and radiographic outcomes were assessed postoperatively and at 6-month intervals. The mean follow-up period was 25.7 months (range 24-47 months). Successful fusion was documented in 226 patients (86.6%). A stable, fibrous union developed in 33 asymptomatic patients (12.6%), whereas an unstable pseudarthrosis in two patients (0.8%) required reoperation. There were no cases of infection, spinal fluid leakage, or postoperative hematoma. Complications included transient unilateral upper-extremity weakness (two patients), dysphagia (35 transient and seven permanent), and hoarseness (35 transient and two permanent). In 14 patients (5.4%) radiological studies demonstrated evidence of hardware failure.

CONCLUSIONS

Cervical corpectomy with fibular allograft reconstruction and anterior plating is an effective means of achieving spinal decompression and stabilization in cases of anterior cervical disease. Symptomatic improvement was achieved in 99.2% of patients. In their series the authors found a fusion rate of 86.6% and rates of permanent hoarseness of 3.4%, dysphagia of 0.7%, and an instrumentation failure rate of 5.4%.

The role of cumulative physical work load in lumbar spine disease: risk factors for lumbar osteochondrosis and spondylosis associated with chronic complaints

OBJECTIVES

To investigate the relation with a case-control study between symptomatic osteochondrosis or spondylosis of the lumbar spine and cumulative occupational exposure to lifting or carrying and to working postures with extreme forward bending.

METHODS

From two practices and four clinics were recruited 229 male patients with radiographically confirmed osteochondrosis or spondylosis of the lumbar spine associated with chronic complaints. Of these 135 had additionally had acute lumbar disc herniation. A total of 197 control subjects was recruited: 107 subjects with anamnestic exclusion of lumbar spine disease were drawn as a random population control group and 90 patients admitted to hospital for urolithiasis who had no osteochondrosis or spondylosis of the lumbar spine radiographically were recruited as a hospital based control group. Data were gathered in a structured personal interview and analysed using logistic regression to control for age, region, nationality, and other diseases affecting the lumbar spine. To calculate cumulative forces to the lumbar spine over the entire working life, the Mainz-Dortmund dose model (MDD), which is based on an overproportional weighting of the lumbar disc compression force relative to the respective duration of the lifting process was applied with modifications: any objects weighing >or=5 kg were included in the calculation and no minimum daily exposure limits were established. Calculation of forces to the lumbar spine was based on self reported estimates of occupational lifting, trunk flexion, and duration.

RESULTS

For a lumbar spine dose >9 x 10(6) Nh (Newton x hours), the risk of having radiographically confirmed osteochondrosis or spondylosis of the lumbar spine as measured by the odds ratio (OR) was 8.5 (95% confidence interval (95% CI) 4.1 to 17.5) compared with subjects with a load of 0 Nh. To avoid differential bias, forces to the lumbar spine were also calculated on the basis of an internal job exposure matrix based on the control subjects' exposure assessments for their respective job groups. Although ORs were lower with this approach, they remained significant.

CONCLUSIONS

The calculation of the sum of forces to the lumbar spine is a useful tool for risk assessment for symptomatic osteochondrosis or spondylosis of the lumbar spine. The results suggest that cumulative occupational exposure to lifting or carrying and extreme forward bending increases the risk for developing symptomatic osteochondrosis or spondylosis of the lumbar spine.

Destructive spondyloarthropathy of the cervical spine in long-term hemodialyzed patients: a five-year clinical radiological prospective study

OBJECTIVE

To describe the radiographic features and progression of cervical spine destructive spondyloarthropathy (DSA) in hemodialyzed patients, and to evaluate the relationship between this disease and patient characteristics, biochemical values, and hemodialysis duration.

DESIGN AND PATIENTS

Standard radiographs, and lateral flexion and extension views of the cervical spine, were performed annually for 5 years in 31 hemodialyzed patients who were divided into three groups at the commencement of the study: those showing (I) DSA, (II) vertebral rim erosions (VRE) without DSA, and (III) absence of DSA and VRE. Magnetic resonance (MR) imaging and computed tomography (CT) were performed in seven and two patients respectively. The imaging features were evaluated for the presence and progression of spondyloarthropathy and correlated with clinical and biochemical variables. Statistical analysis was performed using one-way analysis of variance.

RESULTS

The duration of hemodialysis appeared to be the main predictive factor (P=0.0003) for DSA, which was found in six patients (19%). DSA was found to correlate with higher levels of beta2-microglobulin (P<0.00001), parathyroid hormone (P<0.05), and alkaline phosphatase (P<0.05). Clinical symptoms were minimal. In two patients, MR imaging revealed changes mimicking spondylodiscitis. In another patient, CT of the craniocervical junction showed bone resorption due to a pseudotumor, and basilar invagination.

CONCLUSIONS

DSA of the cervical spine is often clinically silent. Pathogenesis of DSA may be multifactorial but its progression is most influenced by the duration of hemodialysis. On MR imaging, DSA may mimic spondylodiscitis.

Cervical spondylotic amyotrophy with intramedullary cavity formation

STUDY DESIGN

A case report.

OBJECTIVE

To show that an intramedullary lesion was the cause of cervical spondylotic amyotrophy.

SUMMARY OF BACKGROUND DATA

Cervical spondylotic amyotrophy is the clinical syndrome characterized by muscle wasting and weakness in the upper extremities without a remarkable sensory loss or spastic tetraparesis. It is still unclear whether the ventral roots or the anterior horn are selectively damaged.

METHODS

Magnetic resonance imaging and delayed computed tomographic myelography were performed on a patient who showed severe wasting of the left triceps muscle without any sensory disturbance or long tract sign.

RESULTS

On sagittal magnetic resonance images, a linear area was noted within the spinal cord at C6 and C7 spinal segments, which showed low signal intensity on T1-weighted image and high signal intensity on T2-weighted image. On axial T1-weighted image intramedullary low signal intensity area was observed, which was located in the left anterior horn. On axial T2-weighted image the area showed high signal intensity. A delayed (6 hours) computed tomographic scan after intrathecal injection of metrizamide revealed intramedullary enhancement in the area corresponding to the left anterior horn, which would represent cavitation or cystic necrosis.

CONCLUSIONS

This is the first case report of cervical spondylotic amyotrophy, in which intramedullary lesion was confirmed only at the affected side of the spinal cord.

Comparison of axial and flexural stresses in lordosis and three buckled configurations of the cervical spine

OBJECTIVE

To calculate and compare combined axial and flexural stresses in lordosis versus buckled configurations of the sagittal cervical curve.

DESIGN

Digitized measurements from lateral cervical radiographs of four different shapes were used to calculate axial loads and bending moments on the vertebral bodies of C2-C7.Background. Osteoarthritis and spinal degeneration are factors in neck and back pain. Calculations of stress in clinically occurring configurations of the sagittal cervical spine are rare.

METHODS

Center of gravity of the head (inferior-posterior sella turcica) and vertebral body margins were digitized on four different lateral cervical radiographs: lordosis, kyphosis, and two "S"-shapes. Polynomials (seventh degree) and stress concentrations on the concave and convex margins were derived for the shape of the sagittal cervical curvatures from C1 to T1. Moments of inertia were determined from digitizing and the use of an elliptical shell model of cross-section. Moment arms from a vertical line through the center of gravity of the head to the atlas and scaled neck extensor moment arms from the literature were used to compute the vertical component of extensor muscle effort. Segmental lever arms were calculated from a vertical line through C1 to each vertebra.

RESULTS

In lordosis, anterior and posterior stresses in the vertebral body are nearly uniform and minimal. In kyphotic areas, combined stresses changed from tension to compression at the anterior vertebral margins and were very large (6-10 times as large in magnitude) compared to lordosis. In kyphotic areas at the posterior vertebral body, the combined stresses changed from compression (in lordosis) to tension.

CONCLUSIONS

The stresses in kyphotic areas are very large and opposite in direction compared to a normal lordosis. This analysis provides the basis for the formation of osteophytes (Wolff's Law) on the anterior margins of vertebrae in kyphotic regions of the sagittal cervical curve. This indicates that any kyphosis is an undesirable configuration in the cervical spine. Relevance. Osteophytes and osteoarthritis are found at areas of altered stress and strain. Axial and flexural stresses at kyphotic areas in the sagittal cervical spine are abnormally high.

[Dynamic observation on imbalance of dynamic and static forces and degenerated cervical intervertebral disc in rats]

OBJECTIVE

To study the relation between biomechanical imbalance and the degree and course of degeneration of cervical intervertebral disc in rats.

METHODS

Sixty SD rats, 8 months old, were randomly divided into 6 groups, the control and model groups of 3, 5, 7 months, 10 in each group. The cervical disc dynamic and static forces imbalance of degeneration model was established to assess the degree of degeneration as well as the content some inflammatory mediators (prostaglandin E2, 6-keto-prostaglandin F1 alpha) and collagenase (MMP-1) activity.

RESULTS

(1) In 3 months model group and 5 months control group, fibrous ring of intervertebral disc showed some fissure and slight irregular arrangement, nucleus pulposus shrunken or became smaller, mild herniation of nucleus pulposus was seen in some disc. The nucleus pulposus of intervertebral disc in 5 months model group was fibrosed completely and the disc in 7 months model group herniated or became osteophytosis. (2) Compared with the control group of same time period, MMP-1 was increased significantly in the 5 months and 7 months model groups (P < 0.05), and prostaglandin E2 and 6-keto-prostaglandin F1 alpha elevated in the model groups (P < 0.05, P < 0.01). (3) Comparison between model groups, MMP-1 activity in 5 months and 7 months groups was higher than that in the 3 months group (P < 0.05), and 6-keto-prostaglandin F1 alpha was higher in 7 months group than that in 3 months group (P < 0.05).

CONCLUSION

Cervical intervertebral disc undergoes a progressive degenerating process. By breaking the dynamic-static balance of neck in rats could accelerate the progression of degeneration. The fact could be used to elucidate the theory of pathogenesis of cervical spondylopathy, dynamic force imbalance in priority and static force imbalance in predominance.

[Arthrosis--a single or many diseases?]

The classical features of osteoarthritis (OA) include osteophytosis, joint space narrowing, subchondral cyst formation, sclerosis, deformity and low-grade synovitis. OA has been tacitly assumed to be a homogeneous disorder and dismissed as "degenerative". This short article will seek to challenge this traditional view and suggest that at least two major processes emerge from detailed radiological studies in patients with OA. One comprises osteophytosis associated with hyaline cartilage thinning and perhaps joint instability. This may represent a normal response to joint instability, and be seen as a healing mechanism. The other, when subchondral sclerosis and bone attrition predominate, may reflect joint failure.

Surgical treatment of cervical destructive spondyloarthropathy (DSA)

STUDY DESIGN

Sixteen patients with hemodialysis-associated cervical spine disorders underwent surgical treatment. After analysis of the surgical results, the optimum surgical procedures for these disorders were discussed.

OBJECTIVE

To evaluate the surgical results of cervical spine disorders associated with long-term hemodialysis and to propose the optimum surgical procedures for successful outcomes.

SUMMARY OF BACKGROUND DATA

There have been few reports regarding surgical results of hemodialysis-related cervical spine disorders. Surgical treatment for this disorder is still challenging.

METHODS

Sixteen patients with hemodialysis-associated cervical spine disorders were treated surgically. Duration of hemodialysis ranged from 8 to 27 years (average, 17 years). Before surgery, 14 patients showed severe cervical myelopathy, and the other 2 had radiculopathy in the upper extremities. Ten patients with marked destructive changes underwent circumferential reconstructive surgery involving pedicle screw fixation, anterior strut bone grafting, and posterior and/or anterior decompression. Two patients with cervical radiculopathy underwent posterior nerve root decompression by foraminotomy and fusion by pedicle screw fixation or spinous process wiring. The remaining four patients without spinal instability underwent posterior decompression by open-door laminoplasty.

RESULTS

Two patients died during follow-up. Follow-up periods in the surviving 14 patients ranged from 25 months to 92 months (average, 53 months). Marked neurologic recovery was obtained in all patients after surgery. Successful spinal fusion was obtained in all patients except one who underwent posterior fusion by spinous process wiring. Progressive destructive changes with significant instability at the adjacent mobile segments were observed in two patients who underwent circumferential fusion with a pedicle screw system more than 2 years after the initial surgery.

CONCLUSIONS

The pedicle screw system achieved a high fusion rate in reconstructive surgery of cervical destructive spondyloarthropathy, even in the presence of severe bone fragility.

Contralateral spondylolysis and fracture of the lumbar pedicle in an elite female gymnast: a case report

STUDY DESIGN

The case of an elite female gymnast whose pathology started in her 12th year and whose evolution has been exceptional is reported.

OBJECTIVE

To present a fracture of the right lumbar pedicle showing complete spontaneous consolidation despite gymnastic practice 15 hours a week.

SUMMARY OF BACKGROUND DATA

Lumbar pain, which has an incidence of approximately 75% among young athletes, often results from diseases of the posterior arch of vertebrae in gymnasts, including spondylolysis. The association between unilateral spondylolysis and fracture of the contralateral lumbar pedicle in young athletes is poorly described.

METHODS

An elite young female gymnast underwent clinical examination and lumbar radiographs (as systematically required by the French Federation for high-level gymnasts) from 1994 to 1997 to join a sports program in gymnastics.

RESULTS

Clinical examination and lumbar radiographs systematically required of an asymptomatic female gymnast allowed the condensation of the right pedicle to be observed before lysis of the left isthmus of L5 in 1994, unilateral lysis of the left isthmus of L5 in 1995, a right pedicular fracture of L5 in 1996, and healing of the pedicular fracture in 1997.

CONCLUSION

Inconsistency between radiographs and clinical observations can be noted, and spontaneous consolidation of pedicular fractures can occur despite the practice of the gymnastics 15 hours a week.

[Mechanisms of incidence and specifics of spondylolysis and spondylolisthesis course in vertebral osteochondropathy]

There were studied up the morphofunctional changes of vertebral motor segments in 21 patients with vertebral osteochondropathy as well as with initial spondylolysis and spondylolisthesis. The patients were from 12 to 21 years old, the average follow-up was 4.5 years. In vertebral deformity in sagittal plane the spondylolystic spondylolisthesis was not revealed in patients, and in particular the leading clinical sign presented was the syndrome of spondyloarthrosis on the level of compensational hyperlordosis; in vertebral osteochondropathy with preserved or the smoothed physiologic vertebral curvatures--dysplastic spondylolisthesis with early occurrence of hyperplastic spondyloarthrosis as a consequence of the Schmorl's hernia in middle lumbar vertebral segments and of instability of the lower lumbar segments due to vertebral sliding shift with subsequent occurrence of hyperplastic spondyloarthrosis predominantly on these levels. The presence of hyperplastic spondyloarthrosis in lower lumbar vertebral segments while overextension causes the risk rise of the vertebral canal stenosis occurrence.

Alkaptonuric ochronosis presenting as palmoplantar pigmentation

We describe a 37-year-old woman who presented with palmoplantar pigmentation, thickening and pitting of 4 years duration. Bluish pigmented patches were seen over the sclera of her eyes. Her lumbar spine showed typical calcification of the intervertebral discs. Addition of Benedict's reagent to a urine sample of the patient gave rise to greenish brown precipitate and brownish black supernatant. Alkalinization of urine turned it black. A biopsy of the palmar lesion demonstrated irregular breaking up, swelling and homogenization of collagen bundles in the reticular dermis. Yellow-brown (ochre coloured) pigment was seen lying within the collagen bundles and also freely in the deeper dermis confirming our clinical diagnosis of alkaptonuric ochronosis. To the best of our knowledge this is probably the second report of alkaptonuria presenting with palmoplantar pigmentation.

The degenerative cervical spine: pathogenesis and rehabilitation concepts

The degenerative process associated with spondylosis in the cervical spine has been reviewed. The two compressive syndromes commonly associated with spondylosis, radiculopathy and myelopathy, are briefly reviewed. Except for more severe, multilevel degenerative changes producing neurologic compromise, correlation between degenerative changes and patient symptoms or functional limitations is generally poor. A conceptual scheme for guiding rehabilitation of mechanical neck pain, based on irritability level and the effects of mechanical stress on symptoms, is proposed. Further research is required to test the reliability and validity of categorization schemes like the one proposed. Such schemes based on history and effects of mechanical stresses, rather than solely on degenerative radiographic findings, are necessary to classify patients in meaningful ways that help guide specific rehabilitation strategies and tactics. When meaningful classification schemes exist, treatments matched with specific categories of dysfunction can be tested for effectiveness.

The long-term effects of rally driving on spinal pathology

OBJECTIVES

To investigate the consequences of rally driving on lumbar degenerative changes.

BACKGROUND

Vehicular driving is suspected to accelerate disc degeneration through whole-body vibration, leading to back problems. However, in an earlier well-controlled study of lumbar MRI findings in monozygotic twins, significant effects of lifetime driving on disc degeneration were not demonstrated. Another study of machine operators found only long-term exposure to vibration on unsprung seats led to a reduction in disc height.

DESIGN

Case-control study comparing rally drivers with population sample.

METHODS

Eighteen top rally drivers and co-drivers, mean age 43 yrs (SD, 10), volunteered for the study. The subjects were interviewed and imaged with a MR scanning and lumbar images were analyzed for degenerative findings using a standard scoring protocol previously published. The reference group was composed of 14 men, mean age 55 yrs (SD, 10), selected from a population sample.

RESULTS

Overall results showed no significant differences in lumbar degenerative findings as assessed from MR images between the rally drivers and the reference group; age-adjusted differences were not statistically significant for disc heights, bulges, herniations, end-plate irregularities, or osteophytes.

CONCLUSION

Even extreme vehicular vibration as experienced in rally driving does not appear to have significant effects on disc generation.

RELEVANCE

The study results do not support driving, and its associated whole body vibration, as a significant cause of disc degeneration and question the theory that the higher incidence of back pain among drivers is due to accelerated disc degeneration. Other driving-related factors, such as postural stress, may deserve more attention.

MRI cervical spine findings in asymptomatic fighter pilots

MRI of the cervical spine for evaluation concerning degenerative lesions was performed on asymptomatic experienced military high performance aircraft pilots (mean age 42 yr with mean accumulated flying time of 2600 h), and for comparison on age-matched controls without military flying experience. Young military high performance aircraft pilots (mean age 23 yr with 220 h of flying per person) were also examined. There were significantly more osteophytes, disk protrusions, compressions of the spinal cord and foraminal stenoses in the experienced pilots than in the age-matched controls. Low frequency of low grade degenerative lesions was found in the young and inexperienced pilots.

Degenerative changes of the spine of fighter pilots of the Royal Netherlands Air Force (RNLAF)

HYPOTHESIS

The aim of this study was to examine whether F-16 pilots are at an increased risk of (cervical) spine degeneration.

METHOD

Retrospectively, X-ray slides were examined of pilots of the Royal Netherlands Air Force who were systematically radiographed (at least twice). In total, 316 pilots were evaluated: 188 F-16 pilots and 128 pilots in the control group. Two radiologists, who were blinded as to whether the X-ray films were of F-16 pilots or the control group, examined these X-rays separately. In both groups, the time between the two X-rays was on average 6 yr.

RESULTS

Though the inter-rater agreement of the X-rays was rather low, both radiologists found comparable statistically significant differences between the two groups. In the F-16 group, an increased osteophytic spurring was found at levels C4-C5 and C6-C7, and increased arthrosis deformans was found in the cervical spine. Further analysis of the data of a selected group of pilots, whereby the difference in age between both groups was minimized, showed that the higher mean age of the F-16 pilots was possibly correlated with the increased degeneration in this group. No consistent relationship was found between spinal degeneration and initial radiological status. Also, a clear relationship between spinal degeneration and flying hours could not be demonstrated.

CONCLUSION

These findings suggest that frequent exposure to high +Gz forces might cause premature degeneration of the spine of F-16 pilots. Future research must demonstrate to what extent age, mission, and number of flying hours have influenced the results. An uniform international classification and coding system in combination with establishing an international database is recommended.

Radiological ageing process in the cervical spine of Nigerian women

The study was designed to determine the age of commencement of ageing process in Nigerian women Four hundred (400) consecutive women requesting for cervical spine radiographs where recruited for this study. A study chart was made showing different variables like osteoarthrosis, detached osteophytes, postural ulterations and disk degenerations in a four year period from 1st January, 1993 to 31st December, 1996 the modified Kellgren and Lawrence grading system was used to assess radiographic changes. The highest rate of osteoarthrosis (31.13%) was found in the fifth decade. Incidence of postural alterations of the cervical spine rose sharply in the 5th and 6th decades of life. Grade 2 osteoarthrosis (Kellgren and Lawrence) was commonest (61.3%); Grades 3 and 4 had the lowest incidence (3.45%). Disc degeneration was commonest in the 5th; the most involved disc was C5/C6 and the least involved was C2/C3. It is concluded that the ageing process in the Nigerian women commences in the fourth decade of life, and apparently shows no difference with caucasian women.

Pitfalls and delay in the diagnosis of Pancoast tumour presenting in orthopaedic units

Pancoast tumours present a difficult and peculiar problem. Their clinical manifestations may be extrapulmonary. The underlying lesion may be missed in patients presenting with predominantly orthopaedic symptoms. We present four consecutive cases, which were referred to our clinic and the diagnosis was made with mean delay of 18.5 months from the beginning of symptoms.

Long-term follow-up study of posterior lumbar interbody fusion

To see whether degenerative changes of the adjacent disks are accelerated by fixation of a lumbar segment, 48 patients who had undergone posterior lumbar interbody fusion (PLIF) more than 5 years previously were investigated radiographically and clinically. Narrowing of disk spaces was observed in 31% of the subjects, but it usually occurred at levels proximal to the fusion. The incidence of adjacent disk narrowing was not significantly higher after PLIF, compared with reports on degenerative changes of lumbar disks with aging. Some subjects showed narrowing of disks that were not adjacent to the fused level, suggesting that individual predisposition played a role in disk narrowing. Instability was not seen in any of the subjects. New development or elongation of the traction spurs at adjacent segments occurred at the disks proximal to the fusion. The clinical results were generally satisfactory, despite progression of degenerative changes on radiographs.

High cervical disc lesions in elderly patients--presentation and surgical approach

The incidence of high cervical disc lesions is extremely rare, and the mechanism of their development is unclear. We report these three cases, and discuss the possible mechanisms. We also describe surgical strategies for these lesions. The first and second cases were an 82-year-old male and an 84-year-old male with retro-odontoid disc hernia. The third was an 83-year-old female with a herniated disc at C2/C3. To investigate Aetiological mechanisms of these lesions, we examined the findings on cervical images in extension and flexion, and compared the results in a younger than 80-year-old group and an older than 80-year-old group. The patients underwent surgery via a posterolateral intradural approach. Wide laminectomy and incision of the dentate ligaments enabled access to the ventral space of the upper cervical spinal canal and sufficient decompression. All patients became ambulatory postoperatively without special fixation of the cervical spine. In the younger group, the level mostly loaded during cervical movement was C5/6, however, the levels in the older group were C2/3 and C3/4. In elderly patients, less mobilization of the middle and/or lower cervical spine due to spondylotic change causes overloading at higher levels resulting in high cervical disc lesions. Retro-odontoid disc lesions can be caused by a herniated disc at C2/C3, which migrates upward. Regarding surgical strategy, the posterolateral intradural approach is less invasive and more advantageous for these lesions.

Fatal cervical spondyloarthropathy in a hemodialysis patient with systemic deposition of beta2-microglobulin amyloid

Destructive spondyloarthropathy is a serious complication in patients with end-stage renal disease. We report a case of fatal cervical spondyloarthropathy in a patient on hemodialysis who presented with severe pain in the cervical area. Magnetic resonance imaging (MRI) of the cervical spine showed a soft tissue mass at the cervico-occipital hinge with spinal cord compression and destructive lesions of the cervical vertebrae. The patient became quadriplegic during the MRI procedure and died a few days later. Postmortem examination showed deposition of beta2-microglobulin in the cervico-occipital hinge. A unique feature of this case was the documented presence of systemic beta2-microglobulin amyloid deposits involving the spleen that to our knowledge has not been reported previously. Clinical suspicion and early detection of lesions caused by dialysis-related amyloidosis (DRA) may help to prevent significant morbidity and mortality in long-term dialysis patients.

Lumbar spondylolysis in adolescent athletes

Lumbar spondylolysis is a common cause of low back pain in adolescent athletes. The early diagnosis and treatment of this condition will result in decreased morbidity and an earlier return to full activity for most patients. We report a case of lumbar spondylolysis in an adolescent athlete and review current diagnosis and management of this condition.

Familial cervical spondylosis. Case report

Cervical spondylosis is a disease that is often attributed to aging and considered the result of degenerative changes in the spine. The idea that there is a genetic predisposition to develop diseases of the skeletal elements of the spine has been discussed previously, but has never been proven conclusively. The authors report three cases of severe cervical spondylosis in patients who are first-degree relatives: a mother and her two sons. All three individuals had cervical disc herniations and stenosis at C3-4, C4-5, C5-6, and C6-7, and all three required decompressive procedures. The location and degree of cervical spondylosis were as similar among these three patients as they have been in identical twins reported in other studies. Such familial inheritance of cervical spondylosis has been reported only once. The existence of familial cervical spondylosis is not an unrealistic proposal because other studies have shown that genetics determines the shape of one's spine and that similar spines tend to degenerate in similar ways. Therefore, genetic counseling for a family such as the one reported here may prove to be of great benefit to warn siblings that they are at high risk for cervical spine injury. However rare it might be, familial cervical spondylosis may be a phenomenon that any spine surgeon should suspect in a family with cervical spine abnormalities found in several members.

Allelic variation in the vitamin D receptor, lifestyle factors and lumbar spinal degenerative disease

OBJECTIVE

To describe the relation between spinal degenerative disease, allelic variation in the vitamin D receptor gene, and lifestyle factors in a population-based association study.

METHODS

Random population-based sample of 110 men and 172 women over 60 years of age participating in the Dubbo Osteoporosis Epidemiology Study who had spinal radiographs (performed according to a standardised approach), assessment of lifestyle factors, bone densitometry as well as blood taken for genotyping.

RESULTS

Spinal degenerative disease of varying severity was common in this sample. Multivariate analysis of genetic and lifestyle factors simultaneously strengthened the statistical significance of each indicating the presence of additive gene environment interaction. Allelic variation in the vitamin D receptor gene was associated with severity of osteophytosis (adjusted OR "TT" v "tt" 0.41, 95% CI 0.17, 0.97), presence of disc narrowing (adjusted OR "TT" v "tt" 0.45, 95% CI 0.20, 0.99) and weakly with presence of osteophytosis (adjusted OR "TT" v "tt" 0.47, 95% CI 0.19, 1.16) but not with severity of disc narrowing (OR "TT" v "tt" 1.05, 95% CI 0.40, 2.72) or apophyseal arthritis (OR "TT" v "tt" 0.63, 95% CI 0.24, 1.59). Adjustment for femoral neck bone density did not change these findings suggesting that the association is not mediated through bone density. Presence and severity of spinal degenerative disease increased with age at all sites. Current smoking increased both the presence (adjusted OR 9.70, 95% CI 2.08, 45.1) and severity (adjusted OR 2.91, 95% CI 1.16, 9.03) of spinal osteophytosis with intermediate values for past smokers. Severity of osteophytosis was also independently associated with body mass index and quadriceps strength consistent with a contributory effect of physical loading.

CONCLUSIONS

In this elderly sample, both genetic and lifestyle factors were associated with the presence and severity of spinal degenerative disease. There were site specific differences in associations at the spine, which may be because of misclassification of disease status or may indicate possible environmental and genetic differences in the pathophysiology of spinal degenerative disease. Further studies are required to confirm these findings in different population samples and to further explore potential aetiological mechanisms particularly gene environment interaction.

Management of cervical disc herniation with upper cervical chiropractic care

OBJECTIVE

To discuss the chiropractic management of a patient suffering from multiple complaints, including a herniated nucleus pulposus in the cervical spine diagnosed by magnetic resonance imaging (MRI).

CLINICAL FEATURES

A 34-yr-old man suffered from severe neck, lower back and radicular pain of 1 yr duration. He had previously received care from multiple medical specialists, with little or no results. An MRI of the cervical spine demonstrated a C6-C7 herniated nucleus pulposus. A needle electromyogram examination confirmed the presence of a C6-C7 radiculopathy with radiculopathic changes from C4-C7. X-ray analysis showed that the atlas and axis were misaligned. These X-rays were read manually (with a template) and with computer-assisted digitization. Computerized analysis also measured misalignments at the levels of L4-L5.

INTERVENTION AND OUTCOME

The patient was managed primarily with the Grostic Procedure of upper cervical adjusting by hand. After a period of about 1 month, a series of re-examinations revealed a dramatic improvement in all subjective and objective findings. A follow-up of > 1 yr has shown that surgery was not necessary.

CONCLUSION

This single case study suggests that chiropractic care may be a viable treatment option for patients with cervical disc herniation. Further investigation into chiropractic adjustments as a treatment for this condition should be pursued.

[Occupationally-induced degenerative discopathies in the area of the lumbar spine]

A case-control study comprising 188 male and 160 female cases from an orthopedic's cabin explained occupational risk factors for osteochondrosis, spondylosis, and spondylarthrosis of the lumbar vertebra. The controls (109 men, 130 women) steaming mainly from other physician's offices were free from musculoskeletal symptoms. Age-adjusted odds ratio (OR) were calculated for both sexes. In women elevated ORs were found for working in standing position (OR 2.2 CI 1.31-3.85), for repetitive work (OR 1.9 CI 1.17-3.36), for lifting heavy things up to 20 kg (OR 2.1 CI 1.24-3.67), for working as a secretary (OR 1.8 CI 1.16-3.0) or in a supermarket (OR 2.1 CI 1.05-4.56). Men showed elevated ORs for bending (OR 2.2 CI 1.27-4.08), vibrations of the upper limbs (OR 2.3 CI 1.12-5.02), whole-body-vibrations (OR 2.1 CI 1.14-4.11), working in the metal industry (OR 3.6 CI 1.88-6.89) or as motorists for more than ten years (OR 6.5 CI 1.54-27.99) and working in a humid or cold environment (OR 2.2 CI 1.30-3.72).

Posttraumatic cervical osteophytosis causing progressive dysphagia

Dysphagia is a commonly encountered patient complaint. The differential diagnosis for dysphagia is extensive. One long-recognized etiology of dysphagia is cervical osteophytosis. Degenerative joint disease, ankylosing spondylosis, and diffuse idiopathic skeletal hyperostosis (DISH) can all cause cervical osteophyte formation. We describe a patient with dysphagia and a large cervical osteophyte. Our case illustrates cervical osteophytosis associated with a history of previous cervical spine trauma. Evaluation and management strategies are discussed.

[Destructive spondyloarthropathy of the cervical spine in hemodialyzed patients]

To assess the prevalences and neurological symptoms of destructive spondyloarthropathy (DSA) and other cervical spinal diseases in long-term hemodialysis, a questionnaire survey of the medical histories and subjective sensory-motor symptoms was taken on 191 patients undergoing dialysis for 0.2-23 years (mean 8.6 +/- 6.3) with a mean age of 56.6 +/- 11.8 years (range 23-86). Furthermore, plain radiographic examinations of the cervical spine were carried out in 90% of the patients, and neurologic examinations were also performed on 29 patients. DSA was diagnosed in 18 cases (10%): moderate narrowing of the intervertebral space (NIS-I) in 8, severe narrowing (NIS-II) in 18, ossification of posterior longitudinal ligaments (OPLL) in 6, cervical spondylosis (CS) in 12 and other abnormalities in 6; 104 cases were normal. NIS-I was considered to reflect an early stage of DSA. The age of patients with DSA (mean 61.5 +/- 10.2 years), as well as with CS, was significantly higher than the normal group (52.2 +/- 10.6; p < 0.001), but younger than CS (68.5 +/- 10.0). The duration of dialysis in DSA patients (mean 12.1 +/- 6.0 years) was the longest and significantly longer than normal (7.7 +/- 6.5; p < 0.01) and (:S patients (3.8 +/- 3.0; p < 0.001). Through comparative evaluations of prior histories of the diseases, such as diabetes mellitus, carpal tunnel syndrome, amyloid osteoarthropathy (AOA) and parathyroidectomy, along with large calcification of the nuchal soft tissues on plain films, it was found that DSA, in conjunction with NIS-I, correlated with only AOA (p < 0.05). Subjective sensory symptoms, which consisted chiefly of arthralgic type followed by polyneuritic type, were noted in 60% of all patients and 56% of DSA patients. No significant differences were evident between any two particular groups. The score of subjective motor symptoms of the lower extremities in 5 patients with myelopathy was significantly higher than that in 5 other patients without neurological disorders (p < 0.05). Thirty-eight percent of DSA patients showed myelopathy; the frequency was higher than those of previous similar studies (0 = 5%). In conclusion, this study demonstrated that 1) DSA occurred in 10% of dialysis patients, which was also evident in previous reports (9 = 10%); this prevalence was higher than those of CS or OPLL, 2) DSA correlated with the duration of dialysis and AOA, 3) subjective motor symptoms of the lower extremities could indicate presence of myelopathy whereas subjective sensory symptoms contributed little to differential diagnosis, and 4) a careful neurologic examination can more frequently disclose myelopathy in patients with DSA than so far believed.

Neck injury after repeated flexions due to parachuting

A 37-yr-old, previously healthy officer developed a severe pain in the right shoulder and parethesia in the right I-III fingers during a high-altitude low-opening parachute jump. The pain started after a sudden neck flexion while he was checking the developing canopy, well before landing. Electroneuromyography revealed damage to the right C7 nerve root. Cervical radiography showed severe spondylosis and discus degeneration in the CV-VII region; magnetic resonance image demonstrated posterior disk protrusions in this area. Military aviators flying high-performance aircraft often have similar problems in the cervical spine; they have been attributed to effects of high + Gz forces in association with twisted head positions. Parachutists appear to face similar risks. Selection of the optimal head position during the parachute opening and use of light helmets should be emphasized.

Osteoporosis: past, present and future

Osteoporosis is an old and continuing problem which has been a challenge to medical research and care throughout the history of mankind. After the break-through with estrogen, many new agents as well as nutritional and physical interventions were found to be effective in preventing and controlling osteoporosis. Calcium represents one of the keys to all these methods, especially with the appearance of new highly biologically available forms influencing cell calcium metabolism. It appears to be important to focus our attention not only on the physical properties and strength of bone but also on its calcium storage function. By controlling osteoporosis and restoring the proper calcium storage function of the bone, many diseases of old age which are due to or exacerbated by calcium deficiency and disturbed calcium distribution in the body, such as hypertension, arteriosclerosis and senile dementia, may also be successfully controlled.

Cervical spine in Pfeiffer's syndrome

Studies of cervical spine anomalies in patients with Crouzon's and Apert's syndromes have shown an increased incidence of fusions in comparison with that in the normal population. Currently, only small series of patients with Pfeiffer's syndrome who exhibit abnormalities have been published. The objective was to assess the incidence and pattern of radiological cervical spine abnormalities in patients with Pfeiffer's syndrome. All cervical spine radiographs of 22 patients with a confirmed diagnosis of Pfeiffer's syndrome treated at Great Ormond Street Hospital during the last 10 years were studied. All of the radiographs were reviewed by the craniofacial team along with a pediatric radiologist with experience in the assessment of skeletal dysplasias. Radiological abnormalities included hypoplasia of the neural arches, hemivertebrae, and a "butterfly" vertebra as well as vertebral fusion. Evidence of vertebral fusion was present in 16 (73%) of cases. Fusion of both the vertebral bodies and the posterior elements were noted. C2-C3 was the level most commonly involved, although fusion was noted at all levels within the cervical spine. Block fusions involving multiple vertebrae were noted. Analysis of sequential radiographs in 11 patients revealed evidence of progression in eight patients. These results reveal an incidence of anomalies that is higher than previously reported. The older age of the patients in our study demonstrates the progressive nature of the cervical fusions in Pfeiffer's syndrome.

Large vertebral body, in addition to narrow spinal canal, are risk factors for cervical myelopathy

It is well known that a narrow spinal canal is frequently associated with cervical spondylotic myelopathy. However, few investigators have studied the relationship between the size of the cervical spinal canal and that of the cervical spinal cord. Moreover, no studies mention the correlation between the size of the vertebral body and that of the spinal canal in the pathogenesis of cervical myelopathy. In the present study, we used computed tomographic myelography to measure the size of the vertebral body, spinal canal, and spinal cord in patients who had classic cervical myelopathy and in control subjects. We found that patients with cervical spondylotic had a narrow spinal canal as well as a slender spinal cord in the cervical region. Moreover, the vertebral body is significantly larger in the myelopathy group than in controls. A large vertebral body is thought to be associated with a large osteophyte and large disc protrusion. We conclude that a large vertebral body is another risk factor for cervical myelopathy, along with a narrow spinal canal.

Cervical spondylosis. An update

Cervical spondylosis is caused by degenerative disc disease and usually produces intermittent neck pain in middle-aged and elderly patients. This pain usually responds to activity modification, neck immobilization, isometric exercises, and medication. Neurologic symptoms occur infrequently, usually in patients with congenital spinal stenosis. For these patients, magnetic resonance imaging is the preferred initial diagnostic study. Because involvement of neurologic structures on imaging studies may be asymptomatic, consultation with a neurologist is advised to rule out other neurologic diseases. In most cases of spondylotic radiculopathy, the results of conservative treatment are so favorable that surgical intervention is not considered unless pain persists or unless there is progressive neurologic deficit. If indicated, a surgical procedure may be done through the anterior or posterior cervical spine; results are gratifying, with long-term improvement in 70% to 80% of patients. Cervical spondylotic myelopathy is the most serious and disabling condition of this disease. Because many patients have nonprogressive minor impairment, neck immobilization is a reasonable treatment in patients presenting with minor neurologic findings or in whom an operation is contraindicated. This simple remedy will result in improvement in 30% to 50% of patients. Surgical intervention is indicated for patients presenting with severe or progressive neurologic deficits. Anterior cervical approaches are generally preferred, although there are still indications for laminectomy. Surgical results are modest, with good initial results expected in about 70% of patients. Functional outcome noticeably declines with long-term follow-up, which raises the question of whether, and how much, surgical treatment affects the natural course of the disease. Prospective randomized studies are needed to answer these questions.

Cervical myelopathy caused by pseudoarthrosis between the atlas and axis associated with diffuse idiopathic skeletal hyperostosis

STUDY DESIGN

This is a report of a patient with severe cervical myelopathy due to pseudoarthrosis between the posterior tubercle of the atlas and the spinous process of the axis, associated with diffuse idiopathic skeletal hyperostosis. Radiographs of 170 patients with neck pain were reviewed to identify lesions involving abnormal contact between the atlas and axis.

OBJECTIVE

Based on an analysis of 170 radiographs, the prevalence of the reported condition was estimated.

SUMMARY OF BACKGROUND DATA

A number of histologic studies on pseudoarthrosis involving the lumbar spine have been reported. In contrast, lesions between the posterior tubercle of the atlas and the spinous process of the axis have not been reported in association with cervical myelopathy.

METHODS

Clinical and pathologic features of a patient with pseudoarthrosis between the posterior tubercle of the atlas and the spinous process of the axis were investigated. Radiographs of 170 Japanese patients over 40 years old were examined, and abnormal contact between the atlas and axis was classified into two groups based on the degree of spinal hyperostosis.

RESULTS

Of 170 patients, 53 showed abnormal contact between the atlas and axis. The prevalence of abnormalities in the pronounced hyperostosis group (Forestier's stages II and III) was much higher than in the group with normal or slight hyperostosis. Two men had radiographic patterns showing osteophytes projecting into the spinal canal and associated with marked cervical myelopathy.

CONCLUSION

In the group with pronounced hyperostosis, pseudoarthrosis or a variant can cause serious problems in the upper cervical spine that should not be overlooked.

Sequential MRI studies in patients with cervical cord injury but without bony injury

Sequential magnetic resonance imaging (MRI) of 23 patients who suffered cervical spinal cord injury without bony injury was performed prospectively. The major cord injury detected by MRI was at the C3-4 disc level in 16 patients (70%). Three patterns of signal changes were observed. Enhancement of the injured cord was observed on Gd-DTPA-enhanced MRI in 10 patients and the palsy of these patients was more severe than that of those without enhancement. Enhancement was recognized about 2 weeks earlier than the signal change (from isointense to low intensity) on T1-weighted images. This enhancement might represent necrosis, absorption, and reorganisation of the spinal cord, and appears to be a sign of a poor prognosis or an indication that damage is permanent. Another characteristic imaging finding was a vague high intensity signal in the dorsal column of the spinal cord extending rostrally from the main lesion, which appeared 2-3 months after injury and disappeared around 6 months. This finding represents Wallerian degeneration of the corticospinal tract in the cervical cord. Rigidity of the legs and sensory changes of the fingers became more prominent during this period.

Frequency of cervical spine involvement in rheumatoid arthritis

The cervical spine x-rays of a random number of patients with confirmed rheumatoid arthritis were taken. The presence of atlanto-axial subluxation, atlanto-axial impaction, subaxial subluxation and any other associated abnormalities was noted. The spinal canal diameter was also measured which was not significantly altered in rheumatoid arthritis cases. Cervical spine disorders were seen to occur in 16 cases (69.6%) out of 23 patients. Spondylosis was the most frequent disorder ie, in 10 cases (62.5%) out of 16. Obliteration of the normal lordotic curve and disc lesions occurred in 3 cases (18.7%) each out of 16. The mean spinal canal diameter was 16.30 +/- 2 mm with a range of 13-23 mm. Female patients (73.3%) had an increased cervical spine disorder than males (62.5%). Seropositive rheumatoid arthritis cases (87.5%) were mostly involved in occurrence of disorder than those of seronegative arthritis cases (46%).

Rapidly progressing quadriparesis secondary to cervical pyogenic spondylitis in a patient with Klippel-Feil syndrome

We report a case in which the patient's quadriparesis progressed rapidly secondary to pyogenic spondylitis with an epidural abscess of the cervical spine. The patient had type II Klippel-Feil congenital fusion at C3-C4 that may have obscured clinical symptoms, resulting in a slight delay in the diagnosis of spondylitis. Magnetic resonance imaging (MRI) facilitated the determination of the precise location of the epidural abscess, and anterior debridement of the involved vertebrae followed by iliac strut bone grafting led successfully to the patient's full neurological recovery. The case presented is instructive in illustrating the importance of an early diagnosis followed by the appropriate treatment.

Development of degenerative spondylosis of the lumbar spine after partial discectomy. Comparison of laminotomy, discectomy, and posterolateral discectomy

STUDY DESIGN

The development of degenerative spondylosis after successful operative decompression of the affected nerve root was prospectively evaluated in a comparative case series of 100 patients with a herniated lumbar nucleus pulposus.

OBJECTIVES

The objective of this study was to compare the relative incidence of degenerative spondyloarthrosis after successful posterior laminotomy and discectomy and posterolateral extradural discectomy for decompression of a compromised lumbar nerve root.

SUMMARY OF BACKGROUND DATA

The relationship between the radiographic appearance of degenerative spondylosis and prior operative procedures has been controversial and at times contradictory. The posterior operative approach with a partial discectomy has been associated with a significant incidence of postoperative degenerative spondylosis and intraneural and perineural fibrosis, complications that may be minimized, or perhaps even eliminated, with the posterolateral evacuation of the offending intervertebral disc fragment.

METHODS

Each patient had: 1) not responded favorably to nonoperative treatment, 2) a persistent radiculopathy, 3) correlative imaging studies with no preoperative spondyloarthrosis and 4) minimum 2-year follow-up. Fifty patients were treated by posterior laminotomy and discectomy and fifty were treated by a posterolateral extradural discectomy. Postoperative spondylosis was graded based on the radiographic presence or absence of osteophytes, the intervertebral disc height, the vertebral body alignment and the facet joint changes.

RESULTS

At an average postoperative follow-up of 65 months, the incidence of a one grade increase in degenerative spondylosis was 80% of the laminotomy and discectomy patients as compared to 39% of the posterolateral discectomy patients.

CONCLUSIONS

The increased incidence of spondyloarthrosis with the posterior approach suggests that minimally invasive posterolateral extradural procedures should be considered for the decompression of a compromised lumbar nerve root.

Measurement of cervical canal sagittal diameter in Chinese males with cervical spondylotic myelopathy

BACKGROUND

Cervical canal encroachment can be properly assessed from lateral cervical radiographs either by defining its magnification rate or by a ratio-method. Data of the latter obtained from Chinese males with cervical myelopathy were compared with the data of general population in different age groups.

METHODS

A total of 200 Chinese males were included in this study. Half of them had undergone decompressive procedures for cervical myelopathy, while the remaining 100 cases were volunteers. Sagittal diameters of cervical canal and vertebra were measured from C3 to C6 on lateral cervical radiographs, while ratios (Torg-Pavlov's ratios) of the two reflected the extent of sagittal canal encroachment. Cut-off values and discriminant rates of these parameters in different age groups were obtained by discriminant analysis. The tube-to-film distance was set as 40 inches.

RESULTS

In myelopathic group (age < 55 y/o), Torg-Pavlov's ratios, as expressed by mean +/- standard deviation, were 0.77 +/- 0.12 for C3, 0.75 +/- 0.14 for C4, 0.80 +/- 0.14 for C5, and 0.81 +/- 0.15 for C6. In control group (age < 55 y/o) the ratios were 0.94 +/- 0.12, 0.95 +/- 0.13, 0.97 +/- 0.13, and 0.97 +/- 0.13 respectively. In myelopathic group (age > or = 55 y/o), the ratios were 0.76 +/- 0.09, 0.71 +/- 0.10, 0.73 +/- 0.11, and 0.76 +/- 0.11; while in control group (age > or = 55 y/o), the ratios were 0.93 +/- 0.10, 0.89 +/- 0.09, 0.88 +/- 0.11, and 0.91 +/- 0.12 respectively. The cutoff values and their discriminant rates are also presented.

CONCLUSIONS

The differences of canal sagittal diameter as well as Torg-Pavlov ratio between myelopathic and control group of Chinese males in individual age group were statistically significant. It is concluded that congenitally narrow cervical canal is a major predisposing factor to cervical spondylotic myelopathy.